Let's talk about how not to be an asshole to your patients.

Or, for that matter, to your family members when they're in the hospital.

(Inspired by this post at XOJane, and by my own experience over the weekend.)

I had a patient this past weekend who was, by any definition, a Big Girl. Several inches over six feet, broad and strong in proportion to her height, and well over 300 pounds. She'd had a crazy-ass, rare clot in a weird place that had landed her with us. She also had a relative who, while well-meaning, was a royal pain in the patookus in regards to her weight. The relative, incidentally, was also tall, but very, very slender. And had an obsession: her relative's--my patient's--weight.

So I'm in the room, talking to the patient about her Cray-Cray Clot, and the relative starts in about the patient's weight. "You need to tell her she's fat," the woman says, "and that she needs to lose weight."

This is true. She is fat. She's way the hell over what any rational person would consider a healthy weight.

Nonetheless, she had recently finished a half-marathon. She played tennis twice or three times a week, and led a water-aerobics class a couple times a week. Her mobility was not impaired. Her lipids and blood pressure were normal. Medically speaking, she had no problems at all save an extra hundred pounds.

So I turned to the patient. "Do you own a mirror?" I asked. "Yes" was the reply. "Do you know that you're fat?" I asked. "Yes, of course" said the patient. "Are you aware of research that finds that extra weight can lead to health problems?" "Yes."

"There. Done" I told her relative.

Which brings me to my first rule of dealing with fat people: Do not treat them as though they don't know they're fat. 

As a fat person myself, I am constantly reminded that I'm fat. I can't buy clothes from straight-size stores, I am always the largest person in any group picture, and there are some things I find uncomfortable to do because of my weight, like going down stairs. (Going up stairs is easier on the knees, and my aerobic capacity means I'm often outdistancing my skinny colleagues. Still. . .)

If you're fat, you know it. Please give us fat folk the benefit of the assumption that we have brains.

Then the relative asked me straight out if the Cray-Cray Clot was due to the patient's weight.

It wasn't, and I told her so. It was due to the fact that the patient has a rare clotting disorder that hardly ever shows up in women.

In asking that question, Relative had fallen into the same trap that all the doctors who'd seen Patient had fallen into for months. Despite an unyielding headache and neurological changes, the docs who'd seen her hadn't looked at her brain; instead, they'd blamed her weight for her symptoms. Doing so had led to a three-month delay in diagnosis, incalculable damage to her brain and spine, and a lot of pain.

This is Rule Two: Not everything that is wrong is due to excess weight. Do not be blind to the fact that there might actually be a problem that can't be expressed in BMI.

Back in the day, doctors blamed wandering uteri for everydamnthing that went wrong with their female patients. This is exactly the same thing: blaming the most obvious factor for all the trouble ever. Fat equals wandering uterus in today's medicine. Do not blame fat: look for an underlying cause. Examine your patient's general health and activity level. Dig deeper.

Eventually, Family Member took me aside and asked me to have a serious talk with the patient about her weight. If she would just eat less, Family Member said, all her problems would be solved.

I leave it as an exercise for the reader to determine whether or not this is true. (Hint: it's not.)

By the time you get to be fifty, or a hundred, or five hundred pounds overweight, there are other things going on besides overeating. It's not a failure of willpower or a lack of knowledge and understanding. Thirty years ago, we had that attitude about drug abuse: if the person would Just Say No, things would be unicorns and rainbows and the world a better place.

Really severe obesity is a product of a multitude of factors, most of which have nothing to do with food per se. Therefore, my addressing one facet of the problem by saying "Hey, I just met you, and this is crazy, but you eat like a fucking pig, so cut back, maybe" is not going to help. At best, it's telling somebody something they already know. At worst, and most commonly, it demonstrates a lack of respect for whatever deeper issues that person's dealing or not-dealing with.

Morbid obesity is like heroin addiction: it starts from a place deep in somebody's psyche and has to be addressed holistically.

So here's Rule Three: Fat is not about food. Fat is about something else. Don't insult your patient, or your loved one, by assuming that it's just about the calories.

"If you want to help," I told Family Member, "you could reassure Patient that you love her no matter what her size is, and that you'll be there for her if she needs you. Right now, you're telling her that your love and acceptance is conditional on her being thinner. That's a losing game."

Finally, and without illustrative examples, here is Rule Four:

Fat is a descriptor, just as "strong" or "red-haired" or "really good at eye makeup" is. "Fat" does not mean "lazy" or "slovenly" or "smelly" or "bad."

Fat is just another adjective. Avoid making value judgements about somebody just because they're bigger than you, or--equally important--hating yourself because you're not at an ideal weight.

If I had my way, everybody would feel comfortable being who they are. Nobody would feel bad about how they look or however it is that they don't conform to whichever ideal is in fashion. People would eat greens and trot around enthusiastically and take their baby aspirin daily and be cheerful about their futures.

That's not likely to happen soon, so in the meantime I'll deal with the fracas surrounding fatness.

Loud Cheers! (For several reasons. . .)

Doctor Annoyance is going away. I don't care where or when, though I know when the when will be, and believe me, it's not soon enough: he's going away.

Doctor A has been a thorn in my side now for longer than I care to consider. He's one of those doctors--you know, the ones who can't find a phone number on their own, or who ask you stupid, unimportant questions in the middle of a crisis, or who think they're being cute when what they're really being is totally off the chain and for God's sake will you just TAKE IT DOWN A NOTCH ohmygawd how many times do I have to tell you

. . . .Anyhow, he's going.

And, with him, goes another colleague--one so toxic (as the kids say) that I didn't know how much my work life was being affected.

I wrote a piece t'other day for Scrubs about toxic workplaces and nasty, poisonous coworkers. I hadn't connected that bit of writing with anything that was going on in my own precious unit until now. Turns out I was speaking more truth than I had ever imagined.

For the last two years, my daily life's been made more unpleasant by somebody who can't see the good in anything. Swear to Frog, if this person won the lottery, patented a device to reverse global warming and remove pollution from the air, and cured cancer, all in one afternoon, there would still be bitching happening. Some people are never happy, and this is one of those folks.

And they're leaving. Cue my happy-dance. They're leaving, and they're taking Doctor Annoying with 'em, and for the next week, I am going to be blissed out and just smiling like a fool.

In other Hooray news, I have a confession to make: a sexist, horrible, awful confession:

There is some serious eye-candy happening in my unit these days.

We got a new crop of residents in as part of the half-year switcheroo, and although I know most of them, there are a few lovely strangers to gaze upon. (Yes, yes, I know. They're all young enough to be my children and they're professionals and so on and so forth, but dayum.) HR has also given the go-ahead to hiring what seems to be America's/Australia's/Canada's/Backobeyondistan's Top Model candidates for the night shifts, and all of 'em are orienting, in succession, to the NCCU.

Aside from a I-will-always-say-something-stupid moment when I tried to guess where one of the newbies was from (I guessed Ireland; turns out the correct answer was New Zealand), things have been going swimmingly. Not only are these guys--because they're all male, and what's up with that?--easy on the eyes, they all came in knowing what three-percent saline is for and how to do an NIH stroke scale exam. They're all experienced. They're all certified. All I've had to do the last three weeks is show 'em where the coffee machine is, tell 'em how to access the computers, and turn 'em loose. This is in contrast with what I've been doing lately, which involves equal parts babysitting, computer training, and hand-holding.

Is there an asteroid due to hit soon?

Because, if there is, I want to open my mouth as wide as possible and show it my tonsils before I get blown to cinders. And therein lies the last Hooray bit of news: my two-and-some year's checkup was clean as a whistle.

Dr. Crane said that thing that used to be my mouth looked "beautiful," and as I was getting all puffed up about it, added, "The Prosthetic Elf always does such good work." Still, it's nice to know that I am still officially without evidence of disease. The next exam's in August, and I'll have a good old time freaking out about that, as I'm supposed to get an MRI a week prior.

I'm tempted to deck out an IV pole with streamers and fake flowers and ride it around the unit, waving like Queen Bess at everyone.

Seems my job definition just expanded.

The screaming was so loud that it brought me out of the room nearest the nurses' station with a "What the HELL?"

It was a toddler. I don't know jack about babies, except that they're generally wet at one end and loud at the other. This one was both. This one was open-mouthed, red-faced, screaming its little head off, in the arms of my flummoxed-looking coworker. He (the toddler, not my coworker) seemed to be about walking age, maybe a little younger; a cute kid, aside from that awful noise.

So we took him into one of the larger storage rooms and proceeded to play games like "What's on my head?" and "Can we shut you up with cookies?" Coworker dealt with the diaper while I went back to being a nurse.

After thirty minutes of nonstop hollering (poor kid was really upset), the child's father came back to get him. The child's father is an attending physician--not on the neurocritical care service, thank God--and had come in for morning rounds. His wife was out of town. Apparently babysitters do not exist.

Except in the neurocritical care unit! This is the fourth time in as many weeks that a male, attending physician has brought one or more children with him and left said child(ren) in our care for anything up to an hour. One dude dumped his kids off in the nurses' station break room around lunchtime with hasty instructions to "feed them something and keep them entertained."

I can't even. There are so many things to unpack here that have to take them in list form:

1. It's flu season. Children are, it's generally recognized, moving receptacles of bugs.

2. Hospitals are notoriously dirty places. Kids put everything in their mouths. Bad combination.

3. Nurses are not babysitters. We have things to do, even on weekends.

4. Bitches do not, universally, love babies.

5. Can you imagine what would happen if a resident brought in his or her kids?

6. Oh, God, if a female resident or attending brought in her kids, she'd never live it down.

7. Kids are noisy. It's part of being a kid. Units where stimulation is kept to a minimum is not a place where kids can or should be noisy.

8. You are old and experienced enough to know better.

9. WHAT THE HELL ARE YOU DOING, BRINGING YOUR KID TO ROUNDS? It's not like rounds are a sudden, unforseen emergency. They happen every day at a given time. You have time to prepare, to have a plan A and a plan B and even a plan C, should that be necessary.

Thankfully, the charge nurse of the other CCU that shares our floor said something to the doc. Had I opened my mouth, I would've blasted him to a cinder and salted the charcoal. Still, we wrote him up--the only concrete action we can take when a physician does something so inappropriate.

If this were just one physician, or just one service, it'd be easier to handle. Instead, it's different guys at different times, which means it's a part of the hospital culture. That'll be fun to address.

So, guys, if you're thinking that it's a slow Saturday at Sunnydale General, and that nobody'll mind watching your child for however long you need 'em to, just don't.

Just. Don't.

In Which Auntie Jo Weighs In On A Controversial Subject. . .

I used to own a gun.

It was a gun specifically designed to kill people with as much efficiency and as little subtlety as possible: a twenty-gauge shotgun with a barrel so short it skirted the legal limits, bought without a background check on the grey market, loaded with shells full of buckshot. I didn't buy a twelve-gauge because I'm a lady, and larger shotguns kick like hell.

If I had fired it, it would've put a huge, bloody hole in my target, the wall behind and on either side of him, and anything else within about twenty feet.

I bought it about six weeks before I had surgery, from a guy at work. I paid in cash and felt better, because I knew that in my weakened, post-surgical state, as a woman living alone, I would not be able to fight off any intruder who had gotten past shatterproof windows, steel doors, and Max.

(I still miss Max terribly. I never felt safer than when he was lying in the exact spot where he could see both the front and back doors at the same time. He was a Good Boy.)

Still: I was looking at several weeks, if not several months, of recovery from a nasty surgery. I felt small and alone and afraid, and so I bought a vaguely illegal gun that required no skill to shoot. I'm such a newbie that a friend of mine cleaned and loaded it for me and showed me how the safety worked.

Once I got better, I sold it back to the guy who'd sold it to me, for the same price, as it had not been fired. Now I have a can of wasp spray, which is both blinding and neurotoxic. In the words of my hippie massage therapist, it'll fuck a body up.

Beloved Boy owns a number of guns. He hunts, so he has guns, QED. He has one self-defense weapon, a semi-automatic Czechoslovakian pistol with a reminder to "Owner's Manual: Read Before Using" etched on the barrel. Its clip holds 18 rounds of ammunition which, if it hit you in the right spot, would be instantly lethal. If it were to hit you in the not-right spot, it'd be very messy and damaging. If you hold the trigger down, it shoots, then pauses, then shoots, which (as I understand) is what makes it semi-automatic. It's a gorgeous piece of technology and not one I'd ever want to use.

That said: I support the right of the individual to bear arms. I support the idea and practice of a well-armed local defense force, as exemplified by the National Guard. The Second Amendment and I are buddies from way back.

I do not like semi-automatic weapons with large-capacity magazines. Nobody needs them, and nobody should have them, including Beloved Boy.

Because, frankly, all it takes to kill a human is a single-shot, pump-action shotgun with the correct sort of ammo. Load that sumbitch with the right stuff, and you're pretty much done with the discussion. More than that is way too much icing on the cake.

Guns aren't meant to paint pretty watercolors. You wouldn't use one to wash your car or change a baby's diaper. Guns are meant to kill, whether it's ducks or deer (oh God oh God I know I'll have to roast a duck at some point please don't make me clean it ew) or people. There has to be a limit, a boundary, to the amount of killing any one person can do at any one time.

So yeah, I'm all for renewing the ban on assault weapons. I want limits on high-capacity magazines, because for God's sake, who's going to hunt a fucking deer with a 36-shot clip? If the Tyrants of the Twenty-First Century come after us, they'll be armed with nervines and poison gas and nonlethal weapons that'll make Star Wars look like a children's cartoon. No assault weapon is worth its weight if you're vomiting and having uncontrolled diarrhea from sub-sonic vibrations.

I wish, at the end of the day, that I'd trusted Max more, that I hadn't felt the need to spend money and brain-time on something lethal. I had shatterproof glass and fireproof and kickproof doors and a big, handsome boy with huge teeth; what more did I need? I bought a gun because I felt weak and small and afraid.

And I wonder how many other people feel weak and small and afraid in the face of what life sends them, and compensate by getting an AR-15.

This is what I've learned, in two-plus years of no palate. . .

I got to thinking about this the other night, as I was rinsing out the enormous (well, not enormous, but it feels enormous) hole that goes directly from my mouth to my right sinus:

1. Sinuses catch a lot of stuff.

Seriously. The crap I wash out of my sinuses every couple of days would make a strong man shudder and a scientist's eyes gleam with excitement.

2. You don't know how lucky you are to have a palate until you don't.

You normal people have NO IDEA how much snot you produce. Trust me on this one.

3. I can't eat flour tortillas under any circumstances, and should probably stay away from baked potatoes, Tater Tots, macaroni and cheese, and muffins.

Some things stick to my obturator with the tenacity of an angry giant squid. Other things work their way into my turbinates, to be sneezed out a few days or a week later, causing me great alarm.

4. I am so fucking lucky not to have had to have radiation.

I had a patient today who had radiation to his face and neck and who felt pain while eating a can of peaches. Just chewing had caused a pathological fracture. The surgical response was to remove half of his lower jaw. My pal Mary is dealing with a less-horrible, but still awful, sequel to radiation. I was very, very lucky.

5. When you have something that's considered rare, information and statistics and so on change in a matter of months.

When I started the journey with CANSUH, the stats were that three of every four patients that got what I have, polymorphic low-grade adenocarcinoma, were female. Now it's four men in every five patients. Smoking and drinking seem to have little to no bearing on whether or not you get it. Endogenous or exogenous estrogen no longer matters. Spicy food isn't considered a problem, unless you get some of that Thai long pepper up over your obturator. See comment on point #2.

When I started this whole thing, the assumption was that a complete cure could be had with aggressive surgical resection. Now the understanding is that PLGA can come back seven, ten, even twenty years after resection, and even if radiation was used as an adjunct.

When I started treatment, PET scans were considered the standard for monitoring. Now, given the indolence of the tumor, doctors are questioning how effective technology is. Apparently, a tumor can get to be quite a respectable size before it shows up on scans. Now, hands-on scoping and poking is the latest thing.

Essentially, I got told during my last ENT visit with Dr. Crane that the best I could do was NED--No Evidence of Disease--forever.

Well, shit.

In a way, it sucks to go from "we have a complete cure" to "you have to be careful." In another, it's nice to know where I stand. I never really trusted that "complete cure" thing anyhow. When you've had a piece of your body removed with a bone saw, you tend to get a little spooky about confident predictions.

All of this sounds, in the balance, negative.

However: I'm sitting here, more than two years after my surgery, blogging. I just scratched my own back and felt how incredibly dense and thick my back muscles are. I'm strong, I'm fat (which, if you're in my shoes, is not necessarily a bad thing), I'm back to lifting weights three times a week and running nine-minute miles. I can do yoga without falling over much. The Boy can understand me when I talk without my obturator in, and says it's getting easier to do so with every passing month. (He takes me the way I am; I am so incredibly lucky for that.) I have all but one of my teeth; two if you count the one that was never going to erupt, since it was lying horizontally under my cheekbone.

I look normal. That is such a huge, huge thing. I sound normal. That's even bigger. Two years ago, I wouldn't have believed you if you'd told me that I would *feel* normal with an obturator in--do you remember the struggles I had? I do.

The cancer might come back, or I might get some other type. I'm half-expecting to have to say, "Mother-FUCKER. AGAIN???" when I get my mammogram this year.

The difference between now and two years ago is this: Not only do I know I can survive all the stuff that happened, I know I can do well through and after it.

I can do anything, now. Just about damn near with very few exceptions anything.

In the two days I've had off since the holidays. . .

. . .I've gotten into an Ancient Cookbook Frenzy.

One thing I can say for people in the sixteenth and seventeenth centuries: they had one hell of a collective sweet tooth. Make a pie of artichoke bottoms? Strew it with sugar before you serve it to table. Boil a calve's chaldron (which I just found out is entrails) and spice it with mace and nutmeg and cinnamon? Sprinkle a little sugar over that mofo before you serve it up in a pasty. Roast a rooster? Sugar. Making a nice (meaning exacting) recipe for biskit? Sugar. Sheep's feet? Sugar.

When a recipe starts with "Take a pound of sugar, seirced, and lay it onto four pounds of butter, add enough flower to make a past with rosewater and fresh Milk," you know you're really on to something.

My goal is to find recipes that don't involve too much sugar, like roasted capon with a cream/anchovy/egg yolk sauce, and try to make them. The trick is deciding when "enough" is really enough, as most of the recipes say to bake, boil, or chafe something until it is enough or is meet.

The best instructions I've found so far are for Makeing a Caudle After the French Manner, in which you are directed to Seethe as much Milk as is fit on the Coals of the Fyre, and when little Pimples appear, you are to Take It Off and Coole It by the Fyre until it is Hardened, which, ew.

In that vein, I offer two recipes, primarily for Friend Penny The Lotion Slut, but also for anybody who needs soup. Non-vegetarian alternatives for the first are given in parenthesis.

Auntie Jo's Pseudo-Mexican Veggie and Corn (and Chicken) Soup:

In preparation:

Pour one box of vegetable stock (chicken stock)--Kitchen Basics makes an excellent one--into a very large pot

Set to seethe over a low fyre.

Meanwhile, chop one small or one-half of a large Onyon
Two Peppers, either Poblano or Bell, (but not green bell, because they suck)

And wilt (fry over very low heat) them in a little vegetable oil

Open three cans of beans: one white, one red, one black. Dump them into a colander and run water over them until those weird starchy white bubbles no longer form. This process will take out the fartification chemicals.

(If you want to make this with chicken, now is the time to add your preferred cut of said bird to the stock. When it's simmered enough that there's not actual blood coming out of the meat, you can pull out the meat and shred it, then return it to the stock.)

Add the onion/pepper mix to the stock.

Add one can of petite diced tomatoes with juice.

Pour in enough water that you've got a kind of watery thing going on. You're going to cook this for a good while, so don't be afraid to add plenty of H2O. I usually add about four cups.

Now add your beans. If you have a bag of frozen corn in the freezer, the cheap sort that is sold for fifty cents a bag, add that too. A can of shoepeg or regular corn, well-drained and rinsed, will do as well.

If you're doing this right, you should have about a gallon of very watery soup: enough to make you wonder if this was a good idea. You're doing fine, don't worry. (How I wish this reassurance came in 16th century recipes!)

Now for two spices: cumin and chili powder. You are a fool if you use hot chili powder for the majority of this, since you want to dump in at least a quarter-cup of each. Seriously: you want this sonofabitch to be a dark red color with a hit of cumin to your nose. If you want the heat, you can add a couple tablespoons of hot chili powder about midway through, but don't use all hot; you'll be sad.

Allow to come to a boil to kill off bacteria. Then simmer for several hours, or until it looks like supper. (For reference, I usually have at least an inch of soup-ring around the edge of the pot before I serve it.)

This makes a lot of soup. I freeze about three quarts every time I make it. Serve with shredded cheese and tortilla chips, either on the side or crumbled in. Do not sprinkle with sugar before taking to the table.

Auntie Jo's Weird Pseudo-Tabbouli Thing Made With Kale

I'm actually very proud of this. It keeps forever and tastes better the second, third, and fourth day.

Get you one bunch of kale. Curly or not, doesn't matter. It's cheap, so maybe you should get two.

Get you a bunch of parsley. The flat-leaf Eyetalian kind is best, but you can skate by with that curly stuff.

Get the other half of that onion out of the fridge.

Buy a long English cucumber, one red or yellow bell pepper, and three good tomatoes, if any are to be found in the winter.

Make sure you know where your salt, pepper, olive oil, and lemon juice are.

Be warned: this is a labor-intensive recipe.

Wash your kale in several changes of water. The easiest way to do this is to fill a really big container with cold water, plunge the vegetables in and swish them around, then yank them out. Empty the container and rinse and refill, then repeat. You can't be too careful with kale, as it tends to be sandy.

Do the same with the parsley.

Dry them both by shaking them out, then wrapping them in a dishtowel. Set that mess aside.

Peel and seed your cucumber, or don't peel it. Just seed it. Whatever. Chop it very, very finely.

Chop your tomatoes very, very finely. Save as much juice as you feel like.

Ditto your onion. Ditto your pepper, removing the seeds and weird white membrane first.

If you have garlic, mince a couple of cloves of that, too.

Set all of that aside. Now you're starting the really labor-intensive bit:

Stem the kale. This is most easily done by simply grabbing the leafy parts of the kale and ripping them off the stem. A little stem is okay, but not a lot, as kale stem is best digested if you have four stomachs.

Stem the parsley. You don't have to be as careful with this. As a matter of fact, I usually just cut off the top two-thirds of the bunch and save the rest for stock.

Chop the kale and the parsley together (you should have about equal amounts of each) very, very finely. No, finer. No, finer than *that*. You want the two to be indistinguishable on the cutting board. Seriously: chop it fine fine fine. Otherwise, the kale will be tough.

Mix the kale/parsley stuff with all your other veggies. Salt generously. Use some pepper. Squirt more lemon juice than you think is wise over it, then finish with a dollop of olive oil. Stir. Refrigerate. Eat entire bowlsful for lunch.

Sometimes I add quinoa to this to make it a main dish. Sometimes I just eat it straight out of the bowl, standing in front of the fridge, when I get home from work.

You could possibly use a food processor for the chopping, but only if you're better with a food processor than I am. I got kale and parsley pesto the first time I tried, and haven't gone back.

Do not Boyle with a Large Blade of Mace, or bruise with Sugar, or Bake in Coffin until Fit.

I missed Christmas Day, but. . .

May you all have the Humor of Donna

The Heart of Rose

The Patience of Rory

The Balls of Amy

The Bravery of Martha

The Belief of River

The Courage of Clara

And the Love of Tashi

http://images2.fanpop.com/images/photos//Tardis-in-Space-tardis-6289810-1280-768.jpg

To welcome in this new year.

"But you. . .

. . .you were fantastic."

Arizona north of Phoenix is, as Beloved Pens says, fucking lousy with vistas. Coming up over a series of hills you weren't aware you were climbing, the whole earth opens up to reveal hills the size of small mountains, creekbeds that probably haven't had water in them in years, and is that a mesa out there in the distance?

I trundled along in my speed-governed econo-box, and my mouth dropped open as I topped that last hill on 17. All I could think to say was "Holy. Shit."

Arizona is a weird place. I hadn't been through there in years--the last time was in 1996 or so, and we bypassed Phoenix for Flagstaff--and I had forgotten how you see places in the desert.

The first way is in the details: the grinding sameness of saguaro cactus, which at first is incredible and then just blends in to the sagegrass and the sand. The second way is in a car, where everything moves fast enough that you're taken by surprise by the whole picture when a vista opens right up in front of you. The third way is from a plane. Nothing's human-scale any more; it's a glorious, perspective-less panorama of mountains and dry washes. You wonder, looking at it from the air, if anybody who'd settled the area would've kept going if they'd known what was ahead of them.

I wondered that same thing about Tashi before Kevin's memorial service this weekend. If she'd known what was going to happen, what she'd have to go through, would she have stuck with him? The grinding sameness of the day-to-day chores of dealing with somebody whose brain is altered, when vistas don't open up with the regularity that they do on the highway; what would she have done?

The answer came when Tashi said this: "Even though I only knew him for about a year before the cancer started changing him, he was so amazing that the love he gave me made it worthwhile to stick around."

And, "The cancer never got *him.* He was never his cancer. He was always himself."

Speaking literally, Kevin lost. He died of brain cancer. It won.

Speaking in every way that matters, he won. He owned that cancer, and beat the hell out of it. The proof is in how all of his friends remembered him: a silly, loving, incredible, creative, goofy, loyal man who cared more about other people than he did himself, and loved everybody. Those things that made Kevin Kevin didn't change just because he had a tumor.

I've never laughed so hard at a party in my life, even one where the guest of honor wasn't dead.

Kevin's friends told stories and provided details. Tashi told us what it was like to take care of him when he was sick. The two combined opened up a big, detailed portrait of a person I wish desperately that I'd known. I was honored and lucky to hear all about him, though, and for that I'm grateful.

Tashi said at one point that Kevin was the kind of guy who made other people want to be better people.  I had been thinking that exact same thing just seconds before.

Thank you, Tashi, for introducing me to Kevin. He was fantastic.

RAAAAAAAAAN-dom

I just painted my fingernails a dark, elegant grey. My toenails are a sparkly dark red, except for the nail on the fourth toe on my right foot, which is grey. Tomorrow, when the polish is totally dry, I will decorate the nail on my left fourth finger with bright pink stripes.

This is all for Kevin's memorial service, which is Saturday in Arizona. I will be wearing, per his wishes, bright-colored comfortable clothing (ink blue baggy pants, grape-purple artist's smock with a green t-shirt underneath, Converse and a saffron-dyed scarf from India). There will be, if my Interwebs research is correct, pie available at the service. I am all about pie. Hence the baggy pants.

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The Boy and I are texting. I say he should check out Baker Seeds; he says I should check out Forestry Supply. Little does he know that I already have a wishlist from FS that's as long as your arm.

*** *** *** *** ***

Best salad ever: greens, including baby kale (NOM), bell peppers, tomatoes, cucumbers, corn, black-eyed peas, cheese, FRIED OKRA, little bits of carrot and olive. I'm kind of on a kale kick at the moment, which is good, as the hippies across the street have approximately eight gazillion tons of the stuff to give away. They're desperate. I eat the teeny new kale plants in salad, since it doesn't have to be cooked or massaged or whatever, and the older leaves chopped up for tabbouli.

The folks at Baker Seeds say that kale will grow whenever there's even a hint of warmth in the air or soil. That doesn't really express how kale will take over your garden, your yard, your life, if the air temperature isn't below thirty degrees. It was eighty degrees here today (what the fuck global warming stop it STOP IT) and, sure enough, there were bitty kale sprouts coming up from the ground.

Some say the world will end in fire, some say in ice. I say the world will end in kale and cucumber vines.

*** *** *** *** ***

Speaking of cucumber vines, have I told you guys the story of Mom's killer melons and pumpkins?

*** *** *** *** ***

Or the time she planted luffa gourds and zucchini in the same garden, and they cross-polinated? I noticed that nine of ten blurbs for luffa gourds I saw in gardening catalogs this year noted that they would not cross-pollinate with other squashes. Technology: saving us from weird stir-fried squash.

*** *** *** *** ***

Don't tell The Boy, but I'm thinking of redecorating the bedroom, to make it more Boy-friendly.

*** *** *** *** ***

Attila made me do some weird new back exercise today. Given that I dealt with hemiparetic and tetraplegic patients last week, all weighing over three hundred pounds, I am sore as hell this evening.

*** *** *** *** ***

And that is all for this evening. I'm off to make stripes of Scotch tape and pink nail polish.

So we have this new computer system.

The whole damn thing's been reworked, top to bottom, and it's rumored to be the best, most efficient, most amazing computer system in the history of EVAH. Lab tests and MD notes and medication administration and tiny bits of lint from the dryer are all linked together; all that's linked to some magical whoozit that records when a nurse enters a room, what equipment s/he uses while there, and when s/he leaves. It's rumored, in short, to be the best. damn. thing. since SLICED FUCKING BREAD, MAAAN.

Except, well, it doesn't work.

And I mean, all joking and superlatives aside, it doesn't work.

For instance: let's say you have a patient who wants only one Lortab, rather than the two that were ordered. Instead of pulling two out and wasting one, or just doing an RN override on the Diebold that holds the meds, you have to now call the doctor and get an order for only one Lortab. And then wait for that to be entered and linked and so on.

Yeah.

Let's say you have to waste a partial dose of a medication, like when a patient gets two milligrams of morphine but the morphine comes in four-milligram ampules. The old way to do it was pull, waste at the machine, chart. The new way is pull, have two people scan the med at the bedside, waste at the bedside, do an override to administer 2mg of an ordered medication, then go back and enter the waste at the machine.

And, because everything is now coordinated, Les Machines keep track of how long it takes you to get *back* to the Diebold and waste. If it's more than about a half hour, your administration will get flagged for investigation, because you might be huffing morphine. Which is fine and dandy unless you have five (or six, or eight) patients to deal with. Nurses with huge patient loads often waste everything at the end of the shift.

Let's say you have a person on a heparin drip. Even if you only want to enter the same drip rate hour after hour after hour, you still have to scan the person's armband, scan the bag, and get a witness. This is the new rule for every titrate-able drip in the system. For us, it's not a big deal: we might have one or two drips running in the NCCU on a person. In the med-surg CCU or in the neurosurgical CCU, though, it's a big deal: imagine having to scan-scan-witness-verify for eight drips on each of two patients. Every hour. On the hour.

And, finally, let's say you go into a room that holds a person who's been admitted for a TIA. They're neurologically intact, fine and dandy, and on only aspirin and an antacid. If you leave the room before a certain number of minutes have elapsed when you're giving those meds, you get flagged for not doing sufficient patient teaching on the Tums and Bayer you just administered. If you take too long--that is, if your patient is on six different meds, five of which are new, and the person has questions--you get flagged for inefficiency.

THIS IS WHERE I GET ALL CAPSLOCKY. The trouble with setting up difficult failsafes in a time-crunch-prone profession like nursing is this: once the new checks are set up, all the older ones get scrapped. We no longer have the pop-up windows on our med records that alert us to possible double-dosing. Instead, we have a huge, long, convoluted process to go through that guarantees nothing, as most of our peers are too time-crunched to double-check us.

We learned, less than four hours after the system was implemented, how to get around it. By the end of day shift on Monday, most nurses had copied the scan-codes from med labels and stuck them to the back of their ID cards. We'd also figured out how to copy the med-admin codes from the patients' armbands and stick them to the charts. We worked around the new, cumbersome failsafes. . . .

. . .but we didn't have any other checks or warnings to alert us when we'd fucked up. In other words, our system now has only one point of warning for each patient, and that point has already been sabotaged in the name of saving time.

So we have this new computer system. It reminds me a lot of a story I heard from one of my colleagues. He and his wife bought a gorgeous, brand-new house where everything, from the computer to the thermostat to the hot-water heater, was controlled through the Internet. Their online service provider suffered an outage that lasted three days (he's in the boondocks). During that time, they had no heat. Or hot water. Or air-conditioning. Or TV, phone, Internet, or burglar alarm service. Reprogramming things manually wasn't an option. Why should it be, with this shiny new system?

No system should ever have only one point of failure. Even muskrats and beavers have a back door out of their homes. Manglement's reduced a perfectly workable checks-and-balances system to something with one point of failure, in the name of Patient Safety, and we've already figured out workarounds.

In other news, the hospital-wide campaign to leave our badges in the bathrooms for extended periods of time seems to be working. Manglement might be monitoring our pee-breaks, but we'll work around that, too. (I wonder what they'll say when they see that four of us were in the public men's restroom on the ground floor for six hours on Tuesday?)

Tips for Everybody:

There's nothing like coming in to work, feelin' all efficient and enthusiastic, to find that you're two nurses short in a three-nurse unit. Unless it's finding out that a different department expects your unit to staff theirs for some undetermined amount of time in the morning and again in the afternoon.

Dear Doctors: Please don't wear your ID tags on your belts. Especially please don't do this if you're an observant Muslim, a conservative Coptic Christian, or a member of some other staunchly upright religious group. See, if you've got both a name with eighteen syllables and a strong moral sense, it's gonna be embarassing for both of us if it looks like I'm starin' at your junk while trying to read your ID.

Tip for myself: Next time it seems like a patient is globally aphasic, shaking her head and smiling gently whenever you try to get her to do something, make sure it's not because she speaks only Romanian.

A gentle note to Manglement: top-down initiatives, like locator chips in ID cards, timers in employee bathrooms, and noise-and-motion sensors in nurses' stations and common areas, can and will be hacked.

Many, many thanks to the elevator inspector who sang loudly in the elevator shaft as he was doing a routine inspection of that elevator's braking system.

Also many thanks to whoever it was that joked up a pile of mattresses sitting in a storage room by sticking a can of peas in there, so it peeked out one side.

Best Line of the Night

We've been having some trouble with our sheets lately. We get one size of sheet, but have three sizes of bed. In the past, the sheets fit the largest beds but were a little loose on the other two types. Recently, Manglement decided that knit sheets were better than woven, and so dumped sheets on us that, until they're washed the second or third time, fit every bed beautifully. After the second or third washing, though, you'll hurt yourself trying to get them on to the bed. (I wish I were exaggerating, but one of my coworkers is out with a torn rotator cuff right now. It went when she was trying to change a bed.)

Anyway, Deepa and I were changing a bed under one of our patients, a guy whose stroke had left him both paralyzed on one side and unable to speak easily. Deepa, struggling with the corner of the sheet and unwilling to lift the mattress to force the sheet on to it, exclaimed, "It is so small that we can't get it on!"

Our hemiparetic, expressively-aphasic patient said, clear as a bell:

"That's what *she* said."

Y'all, I am blessed in friends.

Tashi just emailed me. She's starting her own fundraising efforts for Mary.

Tashi.

Who, by all rights, should be allowed to recover and rest and be quiet for a year or more, is fundraising for Mary.

Which proves again what I already knew: I have the best friends ever, and Tashi is the most amazing one of the bunch.

Peeps, we got a job to do here.

Some of you know Mary Osheskie, or read her blog The Bright Optimist.

Mary was one of the first people to contact me privately after I got my cancer diagnosis. She was also the only other oral cancer patient who was a woman and about my age. Her story makes mine look like a walk in the proverbial park:

Mary's a lifelong nonsmoker and nondrinker, so when she was diagnosed with stage III squamous cell carcinoma of her tongue (at an age about forty years younger than is typical, no less) it was a huge shock. She had a partial glossectomy--in other words, the docs took out half her tongue and replaced it with muscle from her arm.

Then she had head-and-neck radiation. Y'all remember how scared I was of radiation. Everything that terrified me, from a tracheostomy to losing every tooth and a bunch of bone, happened to Mary. All of her teeth are gone, her jawbone is jacked beyond recognition in several places, and--as if all that weren't enough--she had a recurrance of the cancer recently and had to have *more* tongue cut out. Luckily, she's fine now, but she still ain't got no teeth.

Now, for your average toothless person, that isn't a problem. You go to the dentist or prosthodontist, you get some implants or some dentures, and you're back to eating apples in a couple of weeks.

Mary's got a different set of troubles. She's got to have posts put into her jaw to hold specially-made dentures in place, because her jawbone alone won't take the stress of the dentures. Plus, most of the bone that's left (after surgeries to remove the dead stuff) is really, really freaking fragile. And of course, after radiation, she's not capable of healing as well as somebody who hasn't been fried.

In short, she has to have an oral surgeon do both the preliminary post-setting and the molding of the dentures, as well as follow her afterwards to make sure there's not further tissue death or infection. It's a big fucking deal.

It's such a big fucking deal that the surgery alone was going to cost $45,000 (US) and not be covered by Medicaid. Mary's on Medicaid because, after having a feeding tube and a trach and a zillion rounds of radiation and hyperbaric dives, she was indigent and disabled.

BUT!! Mary got the news today that her state Medicaid board is going to cover her surgery. She's going to be able to get the posts put in and things ready for a set of dentures. They're even going to cover anesthetic--which, if you read her blog, was not the case for having ALL OF HER TEETH EXTRACTED HOLY SHIT.

So Mary's getting her bone spicules filed down and her posts put in. But she still needs dentures.

She's a thirty-something woman with no teeth right now, and I'd like to help her make that not be the case.

Let me remind you of what you've done in the past: You gave more than eight hundred dollars to the Oral Cancer Foundation, which is run out of the founder's living room, for research and awareness. You gave Tashi Pratt-King a thousand bucks when it looked like she and Kevin (Wash) would lose their home--you guys got her over the hump, and allowed her to keep taking care of Wash until his death this past September. You also bought two Therabites for people with oral cancer who couldn't have afforded them on their own--devices that allowed people to regain the ability to open their mouths more than a few millimeters. Those Therabites, by the way, are still being sanitized and passed around.

And you made me very, very proud and grateful in the process.

Mary needs twenty thousand dollars for dentures. Medicaid won't cover them. Let's do this thing.

Let's commence Operation: Choppers.

Give Forward Fundraiser

Indiegogo Fundraiser

There is also a PayPal link on Mary's blog, linked above.

Thank you, guys.

Happy Coming-Out Day!

I had this whole long post about little old men going septic in my head, but then I just lost the will to type it all out. Instead, let me leave you with a Wayback Machine comparison of what things were like when I was sixteen, versus now, twenty-five years later (as a starting point). . . .

*woo-woo sounds of a time machine ramping up*

Twenty-five years ago, WHAM! put out a video that implied that George Michael was straight. Come to think of it, they also released a single ("Work") that pretty much declared right out that he was straight. (George, George, how little we teenaged girls knew ye.)

This year, a tweener pop star with a devastating hook ("Call Me Maybe") produced a video in which it became apparent that the boy she liked was gay, and the joke was on her.

Twenty-five years ago, I was two years away from making about a dozen friends in Chicago, all of them gay men.

This year, I have one close gay male friend who survived the AIDS epidemic. One.

Twenty-five years ago, as a matter of fact, "AIDS" came into being as a name. The other candidates were LAV and HTLV-III. The name(s) replaced what it had been called, either GRID (gay-related immune disorder) or "gay cancer."

This year, the majority of HIV positive people will be straight women of color, although the rate of HIV infection is again increasing in young gay men, who now see the disease as a manageable chronic condition, rather than the nine-month diagnosis-to-death thing it was in 1986.

Twenty-five years ago, my oldest friend was raped by some guys in our high school. He was targeted because he was gay.

This year, there was a special flag team composed of GLTBQ high-school students in a gay-pride parade in Bigton.

Twenty-three years ago, I saw posters in the windows of restaurants and bars in Chicago that showed the photographs of men suspected of having AIDS. They were put up as a public service to other gay men, so they knew who to avoid. The practice started in San Francisco in the early 1980's, when there was no test for HIV, and people's first symptoms were either Kaposi's sarcoma or PCP pneumonia.

Last week I had to explain Kaposi's sarcoma to a much-younger nurse who'd never heard of it, and who'd never realized that the AIDS epidemic was a big thing.

Fifteen years ago, Ellen DeGeneres came out on television, on the Oprah Winfrey show. That led some obnoxious so-called Christian minister to refer to her as "Ellen Degenerate." (Her response? "I heard that one in the fourth grade.")

Six years ago, Neil Patrick Harris coming out prompted a collective yawn from the public and, as far as I can tell, failed to incense any obnoxious so-called Christians.

Twenty-five years ago, I knew no gay people who were married. This year my friends Joe and George will get married. Deena and Deb have been married for five years and have a second baby on the way, and Sid and Sam are celebrating their tenth anniversary.

Happy CODay to all my gay and genderqueer buddies. Even though all of you are so far out that the closet's now lost beyond the curve of the earth, you all had tough times. Here's to real equality, the valuation of all people on the strength of their character, and the freedom to love whomever you love. Let's work to make it happen in a fraction of the time it took us to get this far.

I need laundry advice.

I can get anything except benzoin stains out of scrubs, but I need help on a non-stain-related issue.

Recently, I got four sets of Wink scrubs. They fit better than Urbane, though they're cut along the same lines: Wink seems to be made with women with hips in mind, while Urbane assumes you're young and athletic and built like The Mankiller, who looks like a boy with boobs.

Anyway, these scrubs. 65% polyester, 35% cotton, tons of pockets. Love 'em.

But even after two wash/dry cycles on Boil and Broil, they are stiff and rustly, and they still have the creases from packaging. How do I get those out?

Do not say "fabric softener." That shit is of the devil and gives me rashes.

Ideas?

Culture clashes and advice for Yankees

For those of you wondering about Tashi, she's doing as well as can be expected. She has good moments and bad ones, but that's par for the course.

We've had an influx of Northerners this summer, so I feel like I can share a little advice with them:

This is central Texas. Things move much more slowly here. Nevertheless, we have been known, while driving, to pass on the right.

Speaking of driving: going the speed limit, unless you're near a known speed-trap, is Not Done here. We have places to be and miles to go, so we generally drive like bats out of hell. Just keep up with traffic and you'll be fine. Don't go the speed limit in the passing lane; you'll likely get killed or yelled at.

I understand that things work differently in Chicago or New York or wherever it is you're from, but here you *can't* be abrasive and expect to get things done. If the movers tell you they'll be there between twelve and three, but you need them to be there right at twelve because you've got the freight elevator reserved from two to four, explain that. Don't, as I heard one person say, snap back, "You will not be there between twelve and three! You'll be there at twelve!" She later wondered why the movers came late and moved slowly. Just be polite. It costs nothing and greases the wheels.

If you have to ask how to "style" "cowboy boots" (they're called just "boots") then you probably shouldn't be wearing them. As Lyle says, buy your jeans a little longer.

The heaviness of the accent does not always indicate the education level, general intelligence, or personal wealth of the speaker.

Women of a certain age are always referred to with "Miz" preceding their first names, and only then if you've been invited to call them by their Christian name. This holds true in most small towns (it does in mine) and some large cities. In fact, it's best not to call anyone by their first name unless you're sure it's okay.

"Ma'am," "Sir," "Please," and "Thank You" are not optional. And don't, unless you want a reputation for being difficult, walk straight up to somebody and tell 'em to do something without first asking how they are and being pleasant.

Bless their hearts, they don't know any better.

Speaking of culture clashes, I was listening to an NPR interview a few weeks ago with a guy who says that culture influences perception of color; in other words, the context in which you're raised determines to a large extent how many colors you see and what you call them. He said, for instance, that the ancient Greeks had so few delineations between colors that they essentially saw in black, white, and bronze.

I snorted mentally at that until the other day, when Friend Deepa, who can't believe my hair, was touching it gently and cooing, "Golden hair, golden hair." Now, my hurr is red--at the most, it could be called strawberry-blonde when I've been out in the sun. When I corrected her, she said positively, "No, your hair is golden." I said, No, my hair is red.

She then pushed back her own hair to show me the earrings that she wears which, like those of most of the Indian women here, are twenty-four carat gold, so pure it's brassy. "Your hair," she pointed out, "is the same color as my earrings. So it's golden."

Point to Deepa. I stand corrected.

GERONIMO!!

Tashi brought Wash's ashes home today in his Tardis urn. This completes this stage of his journey. Next stop: Wherever, Whenever.

Regularly scheduled blogging will resume whenever this localized weather system gets off my face.

Allons-Y, Wash! Good journeys.

Kevin Pratt-King

1985-2012

Prayers for Tashi and Wash, please. . .

Wash is in Hospice right now. He told Tashi on Sunday that he thought he was about to die, watched an episode of Dr. Who, and was unconscious before the end of it.

Please keep them both in your thoughts, but especially Tashi. She proved every day what love is.

Thank you.

In which Jo gets a little pissy about language.

Gifting.

Gifted (passive voice).

Skirting.

When did "gift" become a verb? When did it become acceptable to say that your mother-in-law gifted you with a Precious Moments figurine? How is it okay to say that something is good for gifting or is giftable?

And when did skirting start describing pieces of fabric with buttons at the top? Skirting is either something one does around an issue, or vinyl sold by the linear (not lineal) foot at the mobile-home dealership. One buys a skirt. One does not purchase skirting to wear on one's body, unless one is suiting up for a particularly bizarre costume party. (Halloween costumation ideas, right here on Headly Nursingtons!)

A million years ago, my parents would sit around the breakfast table in their bathrobes, reading out loud from the Wretched-Comical, our local newspaper. Dad went into fits one day over the headline "GIFTABLE SWEATERING," then read the accompanying ad copy out loud with hoots and snorts. I think it might've been 1980 or thereabouts; my sister was home for Christmas break from college. She, being the English major in the house, had lots to say about giftable sweatering.

Then, about a month ago, somebody on my beloved Hairpin used the term "for gifting." The somebody in question was an actual contributor, not a commenter, and nobody called her out on it. Nobody. "Gifting" was okay.

I felt a little like I'd been dropped into a reality I wasn't familliar with. With which I wasn't familliar; whatever. I'm not opposed to splitting the infinitive if it makes reading easier.

I am, however, opposed to gifting and skirting.

(Before anybody asks, yes, I'm poncy about "nursing" as a job description as well. "Nursing" feels like it ought to be limited to breasts and babies. "Being a Nurse is My Bag" doesn't flow, though, and looks crappy on a reusable grocery sack. Yeah, I'm weird.

At least I'll never turn "surgeon" or "patient care aide" into verbs. That's my promisation.)

Well, *that's* never happened before.

Friends and neighbors, I got my ass kicked on Monday.

And when I say I got my ass kicked, I mean I got my ass kicked.

Let me explain: there are a number of unfortunate things that can happen to make a normally nice, cheerful person batshit insane. Things like drug abuse, encephalopathy, encephalitis, vasculits, meningitis, strokes in unusual places, tumors--you get the idea. There's a lot of stuff out there that can hit your brain in such a way that your personality does a one-eighty, but most of those things are very, very rare indeed.

When they hit you, though. . .wow.

Granddaddy came in with a few personality changes and some increased sleepiness (note for new neuro people: your A-number-one sign that there's a problem is irritability and decreased consciousness in tandem) and steadily got worse. He was transferred to us with a Posey vest on, keeping him in his wheelchair as he cussed and ranted.

At some point in the proceedings, he tried to stand up and tip the wheelchair over backwards in order to get out of it. Gweneth, the steadiest and most sensible of patient care aides, was there in a second, keeping Granddaddy from overbalancing, and Stoya went around to his front to see if she could calm him down. I was close behind her. Too close, as it turned out.

Granddaddy threw a punch. Stoya did some sort of Matrix move to avoid it (thank goodness, as it would've messed up her face), and the punch landed squarely in my solar plexus.

Well! I wasn't expecting that at all.

I made a noise like a duck and went down. I'm not ashamed to admit it: have you ever been punched in the gut? I hadn't. I've been hit in the face, which only makes me angry. I've been whacked about the head and shoulders, which is disorienting and painful, but not too handicapping. Being hit in the stomach, though, right in the breadbasket, so hard that the breath gets knocked out of you? You fold up like a sack of potatoes, which I did.

Unfortunately, I folded up right where Granddaddy, still Posey'd in to his chair, could get to me with both fists and feet.

In retrospect, it's funny. It must've looked like something out of a comedy film, or that clip on YouTube where the dude in the Darth Vader costume gets attacked by a playful dog. At the time, though, all I knew was that I was getting wailed on by an angry person with what felt like superhuman strength. Oh, and I couldn't breathe.

Gweneth managed somehow to get the wheelchair unlocked in the middle of all of this and get Granddad out of range. Stoya got his arms, I got the Haldol, and things quickly got better from there.

Y'know, IV Haldol is strongly not recommended, because it tends to cause heart arrhythmias, but at that point, we didn't care. In a few minutes, things calmed down to the point that Grandpa could go back to bed.

The bruises are fading now. He didn't actually hurt me, but he sure woke me up. This is not something you think about when you're taking the NCLEX.

ERMEHGERD SCHNERZZLES

Stolen from CuteOverload. CRANK UP THE VOLUME, PEEPS.

I have the letter!

Yes, my friends, the letter from the OEB that tells me that I am getting Moneys from the insurance people is here in my hot little paw. As I said to La Belle Dame, though, I ain't chillaxin' until that check's cleared.

With my luck, BCBS will skim 90% of it off for processing costs. Which will, of course, lead to the recently-repaired Hell Bolts being sheared again.

*** *** *** *** ***

I have made a new friend.

A few days ago we got one of those patients in: you know the sort, that come without CDs of scans and with minimal information from the transferring hospital. Luckily, this nice little old lady had no medical history, and not because she'd never been to the doctor. She was, at eighty-something, simply that healthy. A lifelong non-drinking, non-smoking vegetarian, she'd had a TIA as a result of a brief dip in her already-low blood pressure.

So, upon her arrival to the NCCU, I paged the dude on call. And paged and paged. Finally, I sent a text page reading "Are you alive? If so, call Jo at XXXX. Minimum three minute rates apply."

The dude on call called me back immediately and apologized. Turns out that between consults and admits at Holy Kamole, he had more than fifteen patients to see. I said I just wanted him to know that I'd gone ahead and entered orders under his name, using the NCCU order protocol, to which he said, "Oh, are *you* the one who entered all those brilliant orders? You clever little thing, you."

"Yes, darling," I said, "I did enter those orders. Now, you'll have to swing by and work your magic on our sweet LOL, but the rest is taken care of for now. Just decide whether you want heparin and let me know, okay?"

"Brilliant!" he replied. "I'll be there as soon as she gets to sleep and the nurses have relaxed for the evening."

He greeted me the next morning, after no sleep, with a muffin. He thanked me for saving him a half-hour's work and making his life easier.

I may have to reassess my attitude toward new fellows.

*** *** *** *** ***

It dawned on me yesterday that when my boss is not around, stupid shit happens much less often.

*** *** *** *** ***

The Apocalypse is nigh: it is August in Central Texas, and I have all the windows open. We've gotten some rain in the last couple of days, and it's now a balmy 70* at just past 0800. All the fans are on, the a/c fan is whirring away, and the cats are napping on the north-facing windowsills.

After two years of really weird weather, this is a relief. This is how it's supposed to be here: daytime highs in the 90's, occasional rains that flood the highways, and brisk mornings. Ever since everydamnthing burned down last year, I've been watching the skies and the winds. Normal is a little disturbing, but I'll take it.

*** *** *** *** ***

Three big things are going to be happening here in the next few months:

1. A template and step-by-step instructions on how to fight insurance companies. Once the template and instructions are up, I'll put permalinks in the sidebar for anybody who wants to use them. Not everybody has the resources and time I do; it's a no-brainer to distill everything I've learned in the last two years, and all the expert help I've had, into something you can fill in, print out, and send off in order to get your money back.

2. HN might be migrating to a new platform. I haven't decided yet. If HN does move, it'll have the same look & feel and the same layout as before, or as nearly as possible.

3. I am dog-hunting. More to come on that as things develop.

Well, well, well.

That appeal? The one that got lost, then found, then didn't have enough paperwork attached?

JUST GOT APPROVED FOR EIGHTY PERCENT REIMBURSEMENT.

They just called.

You may commence celebrating.

Hi. My name is Jo, and I am totally demoralized.

Or not. It's been a rough week.

I talked to the friendly folks at the employee benefits office on Tuesday about the Ongoing Drama Of The Obturator. (For those of you coming in late, the prosthetic I wear to replace my palate/protect my airway/allow me to eat, drink and talk was not paid for by insurance. Given that the whole process cost as much as a new car [Hyundai, not Mercedes], I was a little peeved by that, especially given that the insurance company [Blue Cross/Blue Shield of Texas] first denied that it was medically necessary, then failed to follow their own rules on covering prosthetics.)

So I appealed, all the way to the Office of Employee Benefits. Beloved Sister and I worked up and sent a multi-page appeal letter complete with charts, diagrams, copies of reciepts, photographs of my mouth post-Harrowing, and ninety other things. The nice folks from the OEB asked me to send them a couple of additional pieces of paperwork, which I did. . .and I waited. They told me the whole kit and kaboodle had gone to some doctor who reviews things like this for them, so I waited.

And waited. I had no idea how long it would take for said doctor, who probably has a desk full of appeals, to get his head around mine.

So, when I called on Tuesday, I was expecting that things might not be fresh in the OEB's hivemind, given that the submission date for my appeal was back in March. I was not expecting them to tell me that the case had been closed for lack of documentation.

Well, to be more exact, first they told me that there wasn't anything there. Then they told me that yes, they'd found the file, but it'd been closed for lack of documentation.

Now: given the eight-page letter (with charts, diagrams, and circles and Xes on the back) and the two times I faxed the same information to my contact at the OEB, this was not what I was expecting. The nice contact at the OEB told me it would take her a couple of days to get everything together (right after she told me that everything was printed out and gathered up) for her boss to look at, so he could decide what was going on. So I told her I'd be calling her first thing Friday morning.

I am, to be nice about it, gob-fucking-smacked at this whole thing. I mean, I understand if they deny the appeal. Even though BCBSTX claims to reimburse non-network providers of prosthetics at 60% of cost, and even though they claim to reimburse at standard market rates (manifestly untrue; they actually reimburse less than Medicare or any other provider), I can see that they could finagle a way to deny my claim. That is, after all, their business.

Let me be a little more clear for you: The purpose of an insurance company is not to leverage your premiums into providing efficient, quality care for you. The purpose of an insurance company is to make money for their shareholders.

However, going back to the OEB: the University of Texas is a huge system, with many, many employees. The Office of Employee Benefits is, by necessity, the sort of bureaucracy that can handle that volume of employees. You would think that they could, at some point, have sent me a letter--not a certified letter or a wax-sealed scroll via elephant, just a letter--to tell me that they'd closed my file because I hadn't submitted some document or another.

Or, alternatively, they could've contacted me at the address, two telephone numbers, or email address that they had to let me know they needed more paperwork.

But they didn't.

Somewhere, somebody fucked up. I intend to find out who it was, and make them figure out how to fix it.

At first I was coldly enraged. I told Beloved Sis that the noise she was hearing was the sound of the bolts that hold Hell down shearing loose. Then I spent two days feeling horribly sick and depressed and stressed out. It's amazing how canalized anxiety becomes in the body.

Now I'm just peevish and determined.

Peevish. And determined. Very determined.

Odds, Ends, Updates

OEU the first:

I saw Dr. Crane today and had my tongue yanked around and both of his hands in my mouth at the same time. The exam was clean, the MRI looked "great" (his words; he's not given to superlatives) and I don't have to see him again until February. I won't have any scans then, either.

I said, "No scans?" He told me that at two years, in his experience, it's safe to begin backing off the surveillance scans and just go with eyes-on exams. It's simultaneously exciting and weird to know that my interior doesn't have to be irradiated for everybody's psychological comfort. I worried before every scan; now I'll worry that I'm not *having* scans.

"Nearly cured" is a strange place to be.

OEU the second:

Now that I've told Mom, it's time to tell you guys: I'm dating somebody. Seriously. As in, Talking Marriage Serious. He's marvelous beyond description, with just enough of the annoying human things that everybody has to keep him normal, and I've known him since we were both teenagers. His name is Brother In Beer (yes, the one who sent the lovely flowers after surgery). He's intelligent and funny and sweet and writes beautifully and routinely throws himself down rocky hillsides while perched on a bike. (Yes, he wears a helmet.)

I'm pretty stoked.

OEU the third:

Work sucks. We're staffed for twelve in the surgical CCU and have eighteen to twenty patients every day--even our code bed is full--which means that the staffing in the neuro CCU has been short. If everybody in the SCCU is tripled, they can't exactly send two people to help us out in the NCCU with our six or seven patients.

Plus, we've been having a rash of codes lately.

OEU the fourth: 

Aside from the staffing thing at work, things are going really well around here. I've not been *here* as much as I'd like; there's a lot of writing I've been doing for money that cuts into my blog time. As soon as I get this month's stack of articles sent off, though, I'll tell you funny stories about the Guy With No Memory At All and touching stories about bunnies.

Basically, this summer can be summed up in one well-known phrase: Two out of three ain't bad.

Semi-demi-hemi-annual MRI today!

And no, I don't have the results yet. I won't for several more days.

This was how it went:

http://www.marriedtothesea.com/072412/

This was me this morning. . . .

...when I'd discovered I've been drinking decaffeinated coffee for the last ten days.



GIFSoup

This was in my back yard an hour ago.

Yes, they really are that big. That's a tarantula hawk. It's a critter that eats nectar and pollen, but lays its eggs in tarantulas.

And no, that is not my hand. I've seen a lot, and even held a hissing cockroach, but I'm not that butch.

At first, I was terrified. Then I came around to the idea that this incredibly large critter, which kinda hops around in flight, is pretty cool. I just don't go outside when she's around. Luckily for me, they're not a communal species.

So, yeah. Tarantula hawk in my back yard. Friend La Belle Dame Sans Merci posted to my Facebook page, "This means you either have lots of tarantulas in your back yard, or a lot of tarantulas with hatching T-Hawk eggs in them."

I thanked her for being such a fucking comfort in my time of distress.

Good Lord, it is hot. And humid.

I've just done all my cooking for the week, except for assembling salads, which are best assembled at the fifty-ninth minute of the eleventh hour. Protip for those of you too hot to eat real food: cut up a shitload of vegetables all at once and put them into little containers. Assemble your nommable salad before work out of the little containers. Seriously, this is the best thing I ever learned from Serious Salad Eaters.

We got a doohickey to fill out this week from our Big Boss, about how our Lesser Bosses are doing. Instead of boring you with the boxes I checked, I figured I would put down the letter I wrote in my head while assessing my bosses for a dozen things which do not matter to anybody but management:

Dear Big Boss,

You want my opinion on my other two bosses. You even sent me a survey form to fill out at a third-party website, with the assurance that my replies will be completely anonymous and confidential and not be prejudicial to my continued employment with Sunnydale General.

Instead of filling out yet another useless survey (because, really, whether or not I'm being given positive feedback on how I'm doing my job is not a major issue around here), and because I know as well as you do that surveys are neither anonymous nor non-prejudicial, I've decided to tell you what I really want in a boss.

For starters, I'd like fewer of you. I have four at last count: Small Boss, Bigger Boss, you, and your Horizontally-Equal On The Org Chart Colleague. Of those people, I see Small Boss the most, with Bigger Boss coming in a very, very distant second. I've seen you exactly four times in the last two years, and your Horizontal Equal not at all. The way I figure it, it's ridiculous for me to submit memos about how I plan to hang educational posters in the family room for Horizontal Equal's approval, since she's never, to my knowledge, seen the family room I'm talking about. Maybe we could take her out of our org chart's hierarchy? While we're at it, could you either show up regularly or just stay away?

Because, really, your visits here contribute nothing to the smooth running or the "culture" (whatever that is) of the CCU. You've shown up once to bitch about the placement of warning signs, once to introduce me to somebody I'll never see again, once to warn me about a VIP showing up, and once because, I dunno, somebody in Manglement complained that you weren't showing up enough. Honestly, your visits take time away from my patients and fuck up my train of thought. If I had the chance to get used to you, or didn't see you at all, things would be much, much better.

While we're on the subject of bosses, it sure would be nice if my Bigger Boss had an inkling of what happens in a critical-care unit or on a stroke unit. See, he has about six months of CCU experience, and that was years and years ago. Our old boss, whom you chased off, used to lead codes. Our current boss stands around looking impotent and gets in the way. Maybe he could be retrained to work in a critical-care setting, then work a shift or two a month to keep his skills up. That way, we could at least use him as a charge nurse when there are four nurses, all of whom are tripled, and not enough support staff to make a dent in our patient loads.

It would also kick ass if Bigger Boss and Small Boss made sure that people who work in my NCCU actually have the certifications you claim to require for employment here. So far, I'm the only person who works here who has all of them. We've been open three years (in August), and that seems like plenty of time for folks to do the online NIH course and the other required stuff. It'd be awfully nice if I could give report to another nurse and not have them go jaw-sagging blank when I say something like "hemiparesis" or "gaze preference" or "NIH score of 16."

Finally, if you're really dedicated to a complete reworking of the Culture of the Institution, hire some more damn people. If need be, hire unqualified people with a modicum of brains; I'll happily train them. Just get me some bodies up in here, so I'm not forced to work day in and day out with nurses who are floated here from the CVICU. It's not fair to them, and it's not fair to our patients. They can spot a-fib from a mile away, but they're not used to doing neuro assessments and don't understand our BP parameters. Have mercy on the nurses who are more comfortable with a Swan-Ganz than a ventriculostomy, and Get Me Some Damn Staff.

Oh, wait: that wasn't my final point. My final point is this: if you're going to hold me responsible for stuff, and yell at me when it doesn't get done, or pass things off to me, and expect me to work extra and train new people, the title of "Mangler" would be peachy fucking keen. I have to admit that it's not the title I'm after so much as the pay grade. In any event, since we're speaking of Bosses, you're making me a FIFTH layer of boss-ness between the people I work with and the real world, and I'd like to be compesnated for it.

Much love and many happy capybara kisses,
The one who makes sure the plumbing gets fixed,

Jo

In which Auntie Jo lays down the law.

I love my job I love my job I love my job I love my job.

However.

People: Please research the symptoms of whatever disease or disorder you're going to try to mimic. Most physical troubles, including neurological ones, have a certain expected set of symptoms. Even conversion disorder has an expected course: while the physical manifestations of psychological stress might be weird and unexpected and unexplainable by other means, they're consistent.

A stutter that goes away with opiates is not a disease. It's an attempt to get drugs.

Likewise, there's a name for what you're doing: it's "abasia-astasia," and it means "No, she won't fall over and hurt herself; she'll only fall if I'm there to catch her or she's near something soft."

And frankly? If your weakness is distractable to the point that you yourself cannot remember which side you're weak on, I will call bullshit on your shenanigans and send you out the door tout suite.

I don't just have the population of Greater Sunnydale to thank for this; I have the combined Great Minds at Holy Kamole's emergency department. Therefore, I have some law to lay on them:

If you call and ask me to accept a stroke patient, you'd sure as shootin' better have done an NIH stroke assessment on that patient and be able to tell me his score. If you haven't, I'll tell you to call me back once you've assessed the patient, then hang up the phone gently.

Same deal if you call me with a patient who has a constellation of symptoms and you don't know his history. Same deal if you call me and say, "Well, we're not really sure what's going on, but we'd like to send him over to your NCCU."

Same fucking deal, dear doctors, if you call with a ninety-year-old, demented patient who has a temp of 38.2, whose labs show that he's dehydrated and has a UTI, and who is experiencing the same symptoms he had when he had his stroke two years ago. Incidentally, he's therapeutic on coumadin.

And, just as a reminder, if I accept this patient because I want to put a stop to your whining, but specify that he is to go to the regular neurology floor, do not under any circumstances then tell the bed board that I'd cleared him for a bed in the NCCU. The Wrath of Jo will be visited, not upon your grandchildren's grandchildren, but upon you, comprehensively and cheerfully.

This is because, as might be expected in a critical care unit, I actually have sick people to take care of. I got one on a Cardene drip, one with the most labile blood pressure I've ever seen, good Lord what is she doing going from 220 systolic to 77, maybe an abdominal binder would help, and one who is, sadly, getting ready to go home to Jesus due to a combination of factors, not least of which is an infection with some bacterium that only two people have ever gotten before. I got problems, in other words, because I got patients with problems.

Joe-Bob looking for a hit of dilly is not a problem. At least, he's not *my* problem. He's *your* problem. If you try to make him my problem, you'll have another problem, and probably a whole set of problems of varying, interesting types, right after that.

Thank you, as Katniss said, for your consideration.

Good God I love both of these people, whoever they are.

Here

and

Here.

This is what happens when I try to live like a normal person. . .

Neighbor Beth is here. She's wiping down the kitchen as I slowly, slooowly type this, for reasons which will become clear in a minute.

Those of you who follow me on Facebook will know that I had a cheerful afternoon of productve semi-drunkeness with Neighbor Beth (who is Not Good With Blood). After the prosecco had worn off, and with a liter of water and tea under my belt, I mandolined my right ring finger.

There was a sudden spray of blood. Then there was a heartfelt "Oh, SHIT" from me, as I realized that the suddenly-numb sensation in my right paw was due to my having halfway cut off my right ring finger. I tried everything: direct pressure, flour, glue: nothing worked for longer than I care to think about. Poor Beth, who hates her own blood and has a tenuous relationship with other people's blood, mopped up mine for the 40 minutes it took for shit to stop happenin'.

I'm more than a little annoyed that this happened while I was sober. Beth is more than a little annoyed that she had to scrub blood off my spice shelves. AND I had to throw away a perfectly good, blood-soaked tea towel.

None of the zucchini was affected, though. Which is good: we have a Pickle Party coming up in two weeks.

I kind of wish I'd accepted Beth's offer of another bottle of wine. My finger hurts.

Good Frogs. Has it been that long?

I see I haven't posted since the middle of last month. My apologies.

I've been working a lot, which means new stories for you! but I'm also between keyboards at the moment.

More later this week, I promise. Nothing horrible has happened; I've just been busy.

I'm all right; don't nobody worry 'bout me.

Well, not really.

This week we had a party for Neuroscience Nurse's Day, or Week, or Something Along Those Lines. I was interested to see that the woman who holds herself out as the Director of Neuroscience Nursing (a few years' experience as an ortho rehab nurse, followed by a decade in manglement) wasn't there. Ironic, fitting, all that stuff.

I was more bitter than usual these days. *Everything* pissed me off, even stuff that could've worked to my advantage. Good things pissed me off just as much as bad things, and wishy-washy things pissed me off most of all.

For instance, I work with two mid-levels. One is fantastic. The other is a clueless tinpot tyrant with an ego problem. Fantastic Midlevel and Fantastic Case Manager and I had been working on med-surg to rehab placement for a patient under a return agreement with another hospital (his case is complex) since the patient was admitted almost a month ago. It had been arranged that Sweet Complex Guy would go back to his original hospital, since he's a resident of that particular county and can therefore get services for which bill collectors won't hound him. (Some counties in Texas do it right.)

At the absolutely last possible second--and I mean after the ambulance had been arranged (difficult, because he required vasoactives while en route)--Clueless Tinpot stopped Sweet Complex Guy's transfer. The reason? He was afraid that "SCG would end up rotting in a med-surg bed and his family wouldn't be taught what they need to know." Clueless Tinpot decided to try for a "charity bed" in our facility.

As Fantastic Rehab Manager said, "No bed here is a charity bed. I have explained this to Clueless Tinpot Tyrant over and over. Even if that patient meets all of our specifications for discount services, he'll still have people calling him constantly, and his credit will be ruined by the bills."

None of this, I just realized, will make any sense to you unless you're one of the medical club, so let me put it in English:

We had a patient transferred to us by a county facility. That hospital paid all of the patient's bills while he was with us, with the understanding that he would be sent back once we were done with our peculiarly specialized care. The sending facility has systems in place to provide free, quality care to this dude, provided that we sent him back needing specific things.

And Tinpot Tyrant fucked it up. Not only will my nice, sweet, complex-but-promising dude be two hours from his family, he'll have to deal with the demands of our billing department (not fun; I can testify that they screw things up fairly regularly) for the next two years or so.

And I have to deal with this guy daily. Between making sure that he actually writes orders that he's going to yell at us later for not carrying out and being certain that his orders don't suck, I'm already tired. He's slated for a manglement and marketing job soon, and I hope his transition is smooth and speedy.

Seriously: If you have somebody on a high-sodium diet and six additional grams of sodium tablets a day, and they drop their sodium from 139 to 135 after you lower their hot-salt drip for six hours, would *you* write an order discontinuing that drip immediately?

I thought not. Especially if you want to keep their sodium between 140 and 150 to keep their brain from swelling. Three-percent and 23% saline are useful in limited amounts, but they're useful.

Okay. Enough with the overmedical jive.

I miss my dog. He wasn't my baby, or my furbaby; he was my buddy. We were intellectual equals, no question. He was a stubborn asshole at times, but I never knew his judgement to be off. It's very weird, being here without him snoring and shedding and licking Flashes all over. I step over a body that isn't there, in the middle of the night, when I have to pee. My brain twitches toward the back door every day at dinnertime.

I haven't had the vadge yet to go out to the back yard. Yesterday, I thought maybe I could do it today. Now I'm thinking I could maybe manage it tomorrow.

Thank you all for your kind thoughts. They're a huge, huge comfort, even if I can't respond to everybody individually.

Now Flashes wants 'tentions. I'm going to give him some skritches and heat up beans for dinner.

Max.

When I met Max, he was still a puppy. He might've been nine or ten months old, with those perfect white adult teeth that hadn't seen any wear, except where one was exposed to the roots, where his gums had been stripped away.

The Erstwhile Hub saw him on his way to work and called me, saying, "There's a dog trying to die in the empty lot two doors down." My response was, "Not on my watch."

I went and lured him to our front yard and tried to feed and water him, but he didn't eat or drink much. He was emaciated, his eyes and cheeks sunken, and he looked exhausted. I loaded him into the Honda hatchback I had at the time and drove him to a vet I'd not been to before because my usual vet was closed on Wednesdays.

They told me he was probably very old and probably wouldn't make it, and showed me the X-ray of his gut, full of rocks and sticks. For some reason, I said "do what you have to do to save him." They ran two liters of fluid into him over a couple of days, keeping him sedated so he wouldn't chew the IV out of his arm. I went to see him both days, kneeling down by his cage and saying, "You must not die, you must not die."


He had a cracked hip and two cracked ribs and heartworms from hell and torn-up pads. The vets figured he must've been thrown or fallen from the back of a pickup, and walked all the way from the highway to my neighborhood.

When El Erstwhilo and I divorced, I left Max behind. I was moving into a 600-square-foot apartment and working sixteen hour days, and I couldn't take him. Later, when Erstwhilo thought he might be moving to Ireland and couldn't handle the thought of quarantine, I took Max back. I had just bought a house. Having him made everything better; he was the only thing I missed from my marriage.

Max died Saturday. I was out of town, visiting The Boy in Kansas City. My neighbor called to say that he'd gotten up and boofed around the yard that morning, then had lain down to have a nap and had simply not woken up. I got home this afternoon and found him lying where they'd tucked a sheet over him, looking exactly as though he'd just gone to sleep with his head between his front paws.

There were no signs of distress. He'd gone to sleep in his own back yard and woke up on the other side of the Bridge, where there are dozens of mail carriers on crutches and an ice-cream truck with a flat tire.

This is what I'd been praying for. Whatever Thing is there, out there in the Universe, watching over deserving dogs, gave Max a death in keeping with his life: quiet, gentle, without fuss or pain.

He was my Zoater-Bloater Max-Nose Spoon-Hound, and I'll miss him. I'm thankful, though, that his last days didn't involve vets and needles and fear.

Happy Trails, buddy. May many kitty-bellies present themselves for snorgling on the other side. I'll see you in a little while, okay? :)

Y'know how you feel when a friend does something really great?

That's how I feel right now. My pal Nikki, late of "CatsNotCancer," is doing THIS.

Nikki, although you wouldn't know it to look at her, has ovaries of titanium and shoots laser beams out of her eyes. On vacation, she goes to Australia and rubs Great White Sharks on the belly, to which they respond by rolling over and purring. If she meets a rattlesnake while she's out hiking, the rattlesnake bows politely and gets out of the way. Bees fear her. Butterflies worship her. She's dressed by a posse of bluebirds and little woodland creatures every morning, after which she distributes semiautomatic weapons and shoulder-mounted grenade launchers of Truth to all of them, the better to fight for justice.

Because, you know, this lawsuit isn't all she's done. She's also been a hell of a pal to me.

And if BCBSTX doesn't see reason as regards the Obturator of Doom, you can bet I'll be channelling Nikki when I go see them. With a smiiiiiile.

I really need to stop yelling at my boss.

But honestly, when somebody calls me when I've got two phones already ringing off the hook, a patient who's about to code, six people lined up to ask questions about random neuro stuff, a housekeeper with a query about whether or not something obscure needs to be done today or can wait until tomorrow, and four people leaping out of bed in their usual confused way, it is NOT the time to tell me that I have to check the crash cart this month, myself, alone, today.

I *will* snap at you. And, if you're a condescending asshole (sorry, Bossman! But you were!) and point out to me that ICU nurses have a lot to do, too, I will respond by noting that your average ICU nurse has patient care aides, a secretary, a charge nurse, and a manager to do what I am just that moment doing all by my lonesome. I might even respond at a higher-than-normal volume.

It's a good thing that Bossman had me check the cart, as it turns out. Even though it meant that I missed an assessment on one patient (not a big deal; he was stable as a rock) and didn't get lunch until 1430, it was a good thing. Because I found that the crash cart, ostensibly checked by other people on the unit each month for several months, was full of stuff that was expired. As in, expired in 2009.

Now we have a nice, spandy-fresh cart with magnets in their proper places, salem sump tubes that aren't in packaging so old that both it and the tube have become discolored and brittle (holy crap you would not BELIEVE), and the proper number of needles, large and small, and medications, unexpired. It only took me three hours, between answering phones, helping turn patients, resetting monitors, taking delivery of a cartload of supplies, and fixing the computer that decided suddenly to regress to its roots.

I keep reminding myself that I have a mini-vacation coming up next week, and another one a couple of months after that. They don't keep crash carts on planes, do they? . . .*Do* they?

Big Drama at Sunnydale.

Phiddipus audax, the Daring Jumping Spider (how much do you love that name?) is making its summer home in my house. We do this every year: I see a cute black spider with white spots and bluish-green what-d'ye-call-em (those things that the fangs come off of. Not pedipalps, the one that starts with "c") and catch it and put it outside. This year I missed the Mother of All Audax, and she spun a nest at the corner of the wall and ceiling in the kitchen.

After some research, I decided that the thought of several hundred, maybe as many as a thousand, spiderlings was more than I could stomach, and sucked her into the Miele. I feel awful about it, but we need the rain. (Bonus points for the first Minion who understands that last sentence without using Google.)

Sunnydale's NCCU is in the grip of Big Drama these days. A particularly difficult doctor and a couple of grouchy colleagues of mine have made it their mission in life to submit incident reports for everything, and I mean *everything.* Unfortunately, the doctor writes up nurses for things that she, the doc, should've done (like writing orders) rather than get in trouble with *her* boss, and the grouchy colleagues are sending off irate and insulted emails about things like the lack of housekeeping standards 'round those parts.

I got written up for three things, two of which my boss and I agreed weren't really relevant. The third was not only totally justified, but pulled me up short. I've gotten careless about making sure orders get written, so it looks like I've been haring off on my own, making treatment decisions. This is obviously bad. Nurse Jo is going to spend more time checking orders prior to punching out, and probably doing a lot more last-minute running around to fix things as a consequence.

So yeah, I fucked up. I got called on it. Though I'm not crazy about the *way* I got called on it, it's a good reminder that you have to behave like a brand-new nurse all the time in order to make sure you're not getting careless.

The whole shebang also pulled me up short because it made me realize how scatterbrained I've become in the last few weeks. It made me analyze, thoroughly, *why* I might've gotten scatterbrained and careless, and I came up with what I think's a pretty good reason: I'm overburdened.

When I'm primary nurse in the NCCU (we usually have three nurses, with one taking three patients, another taking two or three, and a third helping out in the absence of a patient care aide), I have a patient load of three. These are acutely ill people who are generally leaping out of bed or desatting or doing some combination of the two, sometimes with a third fun thing thrown in.

I'm also charge nurse, dealing with staffing and bed assignments and crises. I'm also acting as secretary, breaking down charts and answering the phones and entering orders. The facilities management and biomedical repair staff deal only with me: they ignore the other day-shift nurses and hold on to their questions or problems until I'm on staff. I'm also the only person who's allowed to do certain tests (with hyperagitated goo and saline), so I do all of the ones in the entire hospital, as well as the clinic next door. Plus, I do around a hundred chart audits a month to make sure we're in compliance with whatever brilliant idea the Joint Commission's come up with this week.

Some of this stuff has *got* to be delegated. The most obvious solution is to delegate the chart audits, probably to the night staff (which will, I'm sure, make me their most favorite person ever). The other stuff, I'm not so sure about. We've got to get more people trained in the more obscure test protocols; the obvious solution is to train the charge nurses for the other CCUs. I'm not sure how well that'd go over, though, as they're just as overwhelmed as I am.

My first step is to chart exactly how much time I spend doing things other than direct patient care. Given that I round three times a day with residents, midlevels, and attendings, then implement whatever they want implemented, I think that charting'll show I'm really busy. Add in all the other stuff, and. . .well, it'll make a good argument for me getting some relief.

And hopefully, if I get some of this crap off of my to-do list, I'll be able to concentrate on what I'm there for: you know, taking care of sick people and not screwing up.

While you're waiting for a real post. . .

For The Boy.